Cardiovascular care

Correlative effect between sac regression and clinical outcomes following endovascular repair in abdominal aortic aneurysm: fact or myth? (2023)

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Type of publication:
Journal article

Author(s):
Al-Tawil, Mohammed; Muscogliati, Eduardo; Jubouri, Matti; Saha, Priyanshu; *Patel, Ravi; Mohammed, Idhrees; Bailey, Damian M; Williams, Ian M; Bashir, Mohamad

Citation:
Expert Review of Medical Devices. 1-8, 2023 Jun 16

Abstract:
INTRODUCTION: Endovascular aneurysm repair (EVAR) has rapidly become the preferred management of abdominal aortic aneurysm (AAA). Sac regression status post-EVAR has been linked to clinical outcomes as well as the choice of EVAR device. The aim of this narrative review is to investigate the relationship between sac regression and clinical outcomes post-EVAR in AAA. Another aim is to compare sac regression achieved with the main EVAR devices. AREAS COVERED: We carried out a comprehensive literature search on multiple electronic databases. Sac regression was usually defined as a decrease in the sac diameter (>10 mm) over follow-up. This revealed that individuals who had sac regression post-EVAR had significantly lower mortality, and higher event-free survival rates. Further, lower rates of endoleak and reintervention were observed in patients with regressing aneurysm sacs. Sac regression patients also had significantly lower odds of rupture compared to counterparts with stable or expanded sacs. The choice of EVAR device was also shown to impact regression, with the Fenestrated Anaconda showing favorable results. EXPERT OPINION: Sac regression post-EVAR in AAA is an important prognostic factor as it translates to improved mortality and morbidity. Therefore, this relationship must be seriously taken into consideration during follow-up.

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Cardiovascular disease morbidity is associated with social deprivation in subjects with familial hypercholesterolaemia (FH): a study comparing FH individuals in UK primary care and the UK Simon Broome register linked with secondary care records (2022)

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Type of publication:
Conference abstract

Author(s):
Iyen B.; Qureshi N.; Roderick P.; *Capps N.; Durrington P.N.; McDowell I.F.W.; Cegla J.; Soran H.; Schofield J.; Neil H.A.W.; Kai J.; Weng S.; Humphries S.E.

Citation:
Atherosclerosis Plus. Conference: HEART UK 35th Annual Medical & Scientific Conference. Virtual. 49(Supplement 1) (pp S4-S5), 2022. Date of Publication: October 2022

Abstract:
Background: Measures of social deprivation are associated with higher cardiovascular diseases (CVD) morbidity and mortality. To determine if this is also seen in subjects with Familial Hypercholesterolaemia (FH), CVD morbidity has been examined in participants in the UK primary care database (CPRD) and in the UK Simon Broome (SB) register using linkage to the UK secondary care Hospital Episodes Statistics (HES). Method(s): A composite CVD outcome was analysed (first HES outcome of coronary heart disease, myocardial infarction, stable or unstable angina, stroke, TIA, PVD, heart failure, PCI and CABG). The measure of socio-economic status/deprivation used was the English index of multiple deprivation (IMD). Cox proportional hazards regression estimated hazards ratios (HR) for incident CVD and mortality [95% CI] in each IMD quintile. <br/>Result(s): We identified 4,309 patients with FH in UK CPRD primary care database (followed from 1988 to 2020), free from CVD, and 2988 SB register participants, with linked secondary care HES records. In both groups, the prevalence of FH was considerably lower in the most deprived quintile (60% in CPRD and 52% in SB). CPRD patients in the most deprived quintile (IMD-5) had the highest prevalence of obesity and of smoking compared to those from IMD quintiles 1,2,3 and 4 (p-value for trend, all <0.001). Compared to least deprived, the most deprived individuals had the highest risk of composite CVD (unadjusted HR 1.71 [CI 1.22-2.40]), however, on adjustment for smoking and alcohol consumption, there were no statistical differences in CVD risk between socio-economic groups. In the FH Register patients there was an increase in the incidence rates and hazards ratios for composite CVD with increasing quintiles of deprivation. After adjustment for age, sex, smoking and alcohol consumption, this effect remained statistically significant (quintile 5 vs 1, HR = 1.83 [1.54-2.17]. Conclusion(s): Patients with FH are underdiagnosed in lower socio-economic groups. In both CPRD and the SB Register the most deprived FH patients had the highest risk of CVD and mortality, but in CPRD but not in the SB register this was largely explained by smoking and alcohol consumption. Clinicians should adopt more effective strategies to detect FH in lower socio-economic groups, and to optimise risk factor management and to support lifestyle changes and medication adherence for this group.

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Fate and Consequences of the False Lumen After Thoracic Endovascular Aortic Repair in Type B Aortic Dissection (2023)

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Type of publication:Journal article

Author(s):Jubouri M; *Patel R; Tan SZ; Al-Tawil M; Bashir M; Bailey DM; Williams IM

Citation:Annals of Vascular Surgery. 94:32-37, 2023 Aug.

Abstract:Background: Type B aortic dissection (TBAD) occurs due to an entry tear in the intimal layer of the aorta distal to the origin of the left subclavian artery where blood enters the newly formed false lumen (FL) and extends distally or proximally to form a dissection over an indeterminate length of the aorta which, over time, may eventually rupture. Thoracic endovascular aortic repair (TEVAR) aims to seal off the entry tear proximally with the stent-graft, occluding the origin of the dissection and excluding the FL. Nevertheless, in some cases, the perfusion to the FL is maintained, hindering the aortic remodelling process and increasing the risk of aneurysmal degeneration and rupture, particularly in the abdominal aorta where evidence suggest that remodelling is slower. This review examines the long-term effects of a patent or partially thrombosed FL on clinical outcomes following TEVAR in TBAD, also highlighting the pathological processes behind negative aortic remodelling. Another aim of this review is to provide an overview and appraisal of the currently available techniques for managing a patent or partially thrombosed FL to prevent long-term morbidity occurring. Methods: A comprehensive literature search was performed using several search engines including PubMed, Ovid, Google Scholar, Scopus, and Embase to identify and extract relevant studies. Results: Evidence in the literature show that a partially thrombosed FL is more dangerous than a patent FL due to the occlusion of the distal re-entry tears, impeding outflow and increasing mean arterial and diastolic pressures, whereas the latter is decompressed via distal re-entry sites. FL thrombosis and satisfactory remodelling is sometimes achieved in as few as 40% of patients after TEVAR due to the maintained perfusion of the FL either at the level of the thoracic or abdominal aorta. However, although the thoracic aorta is predominantly covered by the TEVAR stent-graft, poorer remodelling and more dilation is seen in the abdominal aorta. Several techniques are available to embolize the FL, including the Provisional Extension to Induce Complete Attachment, Stent Assisted Balloon Induced Intimal Disruption and Relamination in Aortic Dissection Repair, candy-plug, and Knickerbocker techniques. Conclusions: The management of TBAD is invariably TEVAR to seal off the proximal entry tear while extending the repair distally to completely exclude the FL. A risk of aortic wall dilatation distal to TEVAR stent-graft remains; hence, regular monitoring and accurate imaging are essential. At present, a patent FL can be treated using a range of different endovascular techniques.

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Clinical indications and triaging for adult transthoracic echocardiography: a consensus statement by the British Society of Echocardiography in collaboration with British Heart Valve Society (2022)

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Type of publication:Journal article

Author(s):Bennett S; Stout M; *Ingram TE; Pearce K; Griffiths T; Duckett S; Heatlie G; Thompson P; Tweedie J; Sopala J; Ritzmann S; Victor K; Skipper J; Shah BN; Robinson S; Potter A; Augustine DX; Colebourn CL

Citation:Echo Research and Practice, 2022; Vol. 9 (1)

Abstract:Transthoracic echocardiography (TTE) is widely utilised within many aspects of clinical practice, as such the demand placed on echocardiography services is ever increasing. In an attempt to provide incremental value for patients and standardise patient care, the British Society of Echocardiography in collaboration with the British Heart Valve Society have devised updated guidance for the indications and triaging of adult TTE requests for TTE services to implement into clinical practice.

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CT coronary angiography significantly changes treatment targets versus coronary artery calcium scoring in high-risk dyslipidaemia patients (2022)

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Type of publication:Conference abstract

Author(s):Graby J.; Sellek J.; Bayly G.; Avades T.; *Capps N.; Shipman K.; Mbagaya W.; Luvai A.; Khavandi A.; Loughborough W.; Hudson B.; Downie P.; Rodrigues J.;

Citation:Heart. Conference: British Cardiovascular Society Annual Conference, BCS 2022. Manchester United Kingdom. 108(Supplement 1) (pp A135-A136), 2022. Date of Publication: June 2022.

Abstract:Introduction Dyslipidaemia accelerates atherosclerosis. Patients with genetic dyslipidaemias, Familial Hypercholesterolaemia (FH) being the most common, are at heightened risk of premature cardiovascular events. However, this risk is heterogeneous within identical genotype diseases, and modifiable with treatment. Coronary imaging identifies subclinical atherosclerosis, personalises risk stratification and treatment targets. Coronary artery calcium scoring (CACS) is first-line for primary prevention. However, calcification is a late-stage process in CAD pathogenesis and the CACS has low specificity in young patients with severe FH. CT coronary angiography (CTCA) may identify non-calcific CAD and high risk plaque (HRP) features unseen with CACS. This study aimed to quantify the impact of CTCA vs traditional CACS on clinical management in real-world asymptomatic Lipid Clinic patients. Methods A retrospective single-centre review of asymptomatic Lipid Clinic electronic patient records with both CACS and CTCA from May 2019 to December 2020. A vignette was compiled for each patient providing all relevant clinical data. CACS was recorded as Agastston score and CTCA as the Coronary Artery Disease – Reporting and Data System (CAD RADS) grading of anatomical stenosis with a modifier for HRP features.Findings were compiled into an anonymised online survey which Consultant Biochemists from across the UK were invited to complete. Data was revealed in a stepwise fashion to the participating clinician: (i) vignette only, (ii) CACS, and (iii) CAD RADS. Clinicians were asked their lipid target and management after each data-point was unblinded. Background information on CACS and CTCA result interpretation was provided prior to participation. Statistical analysis was performed using SPSS v.21 and significance was defined as two-tailed p<0.05. Results 45 asymptomatic patients (55+/-9 years, 49% female) were included. 7 Consultant Biochemists from 6 institutions (4 [67%] tertiary/teaching Hospitals and 2 [33%] district general Hospitals) participated.CACS and CAD RADS assessment of disease burden is presented in Figure 1, with CTCA re-classifying CAD severity vs CACS in 28/45 (62%) patientsLipid targets were altered significantly more frequently with CTCA vs CACS (19% vs 12%; chi2 57.0, p<0.005), even after CACS result available (Figure 2). The LDL target selected was altered by CACS in 12%, and in a further 19% when CAD RADS result was unblinded, which was statistically significant (c2 57.0, p<0.005). This finding was consistent across FH and non-FH patients. Increasing CACS and CAD RADS severity were significantly associated with change in lipid target (c2 54.2, p<0.001; chi2 27, p<0.001), the latter even after a high CACS result was available, as did presence of HRP (chi2 9.3, p=0.002). Conclusion In high-risk asymptomatic dyslipidaemia, CTCA alters treatment targets beyond CACS by demonstrating higher CAD severity burden and HRP. This may differentiate high risk and very high risk patients in an important population.

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A multi-dimensional approach towards implementing the effective use of remote electrocardiographic monitoring - evaluation of clinical correlation and patient experience (2022)

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Type of publication:Conference abstract

Author(s):*Asad M.; Younas W.; *Kazi S.I.; Alaguraja P.; *Makan J.

Citation:Heart. Conference: British Cardiovascular Society Annual Conference, BCS 2022. Manchester United Kingdom. 108(Supplement 1) (pp A74-A75), 2022. Date of Publication: June 2022.

Abstract:Background Inappropriate use of telemetry results in the overuse of limited resources, disrupted provider workflow, higher costs of care, and false alarms with resultant alarm fatigue. Moreover, identifying a useful implementation blueprint is an important component of promoting its appropriate use. Telemetry can influence patient experience during their stay as potentially it can disturb sleep, contribute to delirium, and increase patient frustration and anxiety. We stipulate that even minor adjustments to monitoring practices can influence optimised patient care. We aimed to evaluate the co-existing standards of practice regarding use of telemetry across Shrewsbury and Telford Hospital NHS Trust (SaTH). We implemented a patient-centred approach towards quality improvement by incorporating record of patient experience as a tool to guide effective use of this limited resource across our district general hospital settings. Methods Patients across two hospital sites were selected to conduct a prospective health service evaluation related to the use of telemetry. A likert scale survey was conducted to record patient perspective of telemetry monitoring including a section with an opportunity to provide feedback towards service improvement. The data of patients receiving telemetry was collected from December 2021 to February 2022.American Heart Association (AHA) consensus statement for remote electrocardiographic monitoring was utilized to evaluate the proposed indication for telemetry. However, the rating system helped group patients receiving telemetry monitoring as Class I (definitely indicated), Class II (maybe indicated), or Class III (not indicated). Clinical notes and electronic telemetry system was employed to record parameters including patient demographics; presenting complaint; class (I-III) of indication; whether an indication for telemetry was documented; the length of telemetry; and the details of any significant events that occurred during monitoring including escalation. Where possible, patients were asked to anonymously provide feedback via set questionnaire focusing on quality of care received by the patient. Result(s):Among the 30 patients who were included in our analysis, 7 were females and the average age in our cohort was found to be 72.8. In about 56% of the patients, there was no clear indication mentioned in the clinical notes regarding continuation/discontinuation of telemetry. Based on proposed indication, about 36.66% (11 patients out of which 2 were female) were identified to be at significant risk of an immediate life-threatening arrhythmia (Class I). Among this group, 2 patients were reported to have significant arrhythmia event necessitating treatment. Further analysis revealed that from our cohort, 46.66% (14 patients) had a Class II indication for their telemetry monitoring out of which only 2 patients had a significant event recorded. However, only 16.66% (5 patients) were found to meet the eligibility for Class III indications and none of them encountered a significant arrhythmia. From anonymously filled patient questionnaires, around two-third of the patients reported not being informed about the utility of telemetry and its predicted duration of stay. One-third of patients reported the device to be inconvenient, intrusive and heavy. Conclusions To accomplish a sustainable improvement, a patient-centred approach should be exercised to help identify the gaps in quality of care delivered. Our analysis showed that significant number of patients received telemetry when it was not clinically indicated. The proposed interventions include adopting formal request process for telemetry, predicting its duration, use of patient education tools and exploring compatibility of telemetry device used. Larger scale studies are required to gain more insight into the appropriateness and impact of telemetry in a hospital setting.

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Reduction in cardiovascular disease morbidity of men and women with familial hypercholesterolaemia (FH) associated with availability of high intensity statins: A cohort study using data from the UK Simon Broome Register linked with secondary care records (2021)

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Type of publication:Conference abstract

Author(s):Iyen B.; Qureshi N.; Roderick P.; *Capps N.; Durrington P.N.; McDowell I.F.W.; Cegla J.; Soran H.; Schofield J.; Neil H.A.W.; Kai J.; Weng S.; Humphries S.E.

Citation:Atherosclerosis Plus. Conference: HEART UK 34th Annual Medical & Scientific Virtual Conference. Virtual, Online. 43(Supplement) (pp S5), 2021. Date of Publication: September 2021.

Abstract:Background: Previous studies of the Simon Broome (SB) FH register reported that, compared to the low-intensity statin period (1992-2008), the standardised cardiovascular disease (CVD) mortality ratio in the high-intensity statin period (2009-2015) was 22% lower in men but 115% higher in women. Linkage of the register with Hospital Episodes Statistics (HES) data has now enabled prospective evaluation of CVD morbidity based on inpatient care. Method(s): Standardised Morbidity Ratios (SMbR) compared to age and sex-matched UK primary care patients were calculated [95% confidence intervals] for risk of composite CVD (first HES outcome of CHD, MI, stable or unstable angina, stroke, TIA, PVD, heart failure, PCI and CABG) in men and women under and over the age of 50 years. Result(s): 2,988 (52.5% women) SB register participants had HES records. The SMbR was higher in women than men in both age groups and during both time periods. Compared to 1997-2007, in both men and women aged <50 years the SMbR fell significantly in the 2008-2017 period (8.7[7.3-10.3] vs 17.9[15.7-20.5] and 12.8[10.4-15.7] vs 20.8[17.1-25.4] respectively. By contrast in both sexes in those >50 years in the later time period there was no significant reduction in CVD-admission incidence rates or in SMbR (Men, 6.6[5.3-8.2] vs 5.8[5.0-6.8], Women, 9.2[7.8-10.7] vs 7.5 [6.6-8.5]). Conclusion(s): While the rate of CVD morbidity due to FH has encouragingly fallen significantly over time in both sexes aged <50 years, it has not done so in those >50. This emphasises the importance of early identification and optimal lipid-lowering throughout life for subjects with FH. Funded by the NIHR HTA project 15/134/02 and BHF grants RG3008 and PG008/08.

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Holt-Oram Syndrome: An Incidental Diagnosis (2022)

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Type of publication:Journal article

Author(s):*Gupta M; *Dosu A; *Makan J

Citation:Cureus, 2022 May 11; Vol. 14 (5), pp. e24899

Abstract:Holt-Oram syndrome is a rare autosomal dominant disorder which occurs because of mutations in the TBX5 genes. Most notable manifestations include musculoskeletal deformities, predominantly affecting the upper limbs, and congenital heart defects. Presentation could be multifaceted leading to delay in diagnosis. We describe an interesting incidental diagnosis of Holt-Oram syndrome in a young female adult who accompanied her son to the clinic. He had undergone closure of both atrial septal defect (ASD) and patent ductus arteriosus (PDA) in his infancy. She reported progressive exertional dyspnoea, reduced exercise tolerance, and palpitations; incidentally, she was noted to have right upper limb deformities. These findings prompted further evaluation and thereafter, resulted in a diagnosis of Holt-Oram syndrome.

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COVID-19 disease and cardiac involvement-a local experience (2021)

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Type of publication:
Conference abstract

Author(s):
*Ahmed M.R.; *Islam S.; *Challinor E.; *Ingram T.; *Khan A.

Citation:
Heart; Jun 2021; vol. 107

Abstract:
Aims The aim of this review to assess cardiac involvement in patients with severe COVID-19 patients. We review all patients with COVID 19 disease admitted in our trust requiring transthoracic echocardiograms on their clinical indications. Background Cardiac involvement in COVID-19 disease has been found to be prognostic factor and has been related with higher mortality and morbidity. In a large series with COVID-19 those with heart disease had a fatality rate around 10.5%.1 2 Methods All adult patients who were COVID-19 positive on PCR admitted between March 2020 and February 2021, who had an echocardiogram, were identified through our local database. Their demographics, co-morbid, troponin levels and Pro NT-BNP were analysed. All echocardiograms reports which were finalised by the imaging cardiologist were included in our analysis. Results There were a total of 41 patients who had echocardiograms during their stay in the hospital with COVID-19 disease. Mean age was 70 (range 45-90) years old. There were 70% male and 30% female patients. 12% were diabetic, 49% hypertensive and 40% had previous heart disease. Pulmonary embolism diagnosed in 10% of patients by CT pulmonary angiogram. 56% of patients required high flow oxygen and 21% need mechanical ventilation. Almost all patients had troponin and CRP levels on admission. Mean troponin level 215 and mean CRP levels were 197. Mean D dimer levels 1130, and mean creatinine levels were 138. 92% had evidence of lung involvement in chest X-ray. 13% patients had new evidence of a diagnosis of left ventricular dysfunction on echocardiography. Similarly, 27% had a new diagnosis of right ventricular dysfunction. Mean left ventricular diastolic dimension were 4.6 cm and systolic dimension. 2% had echo diagnosis of left ventricular thrombus echocardiographic studies. Mean PA pressure on echocardiography were 35 mmHg and mean E/A ratio was 1.2. 17% of patients were found to have pericardial effusion but none causing haemodynamic compromise. Conclusion This data suggests high incidence of right and left ventricular involvement in patients with severe COVID-19 disease. We recommend that all patients with COVID-19 disease admitted to hospital and requiring oxygen should have transthoracic echocardiograms during their admission.

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